Hull, Orville Form v&IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fT This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
VillaDEATH, LEGIBLY or ) in which the WRITTEN IdN�DUR occurred
BLE BLACK INK.FILING antL eptance of a CORRECT AND COMPLETE CERTIFICATE OF
Registered No.__
xx� ._...._....._._ _
Dist. No County,Mar re ,, or City Glens Falls
(If city,give street address)
Name of deceased...QB.Y.I.TLE...14.....n.ULL Veteran ilta
Single, married, widowed, (If veteran. give name of War)
sex Male Color White or divorced (write the word) Single Date of DeathMay 214.1959 19
Age 79 Years Months Days Birthplace Q.enAl ur.y
Cause of Death
Certificate was signed by....$P.b.P..t...2.0id M.D.
AddresE .C.Pn...S.t.,....Cry.ana...F.ells
Place of Burial (or Removal)
(If body Is to be temporarily held,fill in space later)
Cemetery.Mt.....Herlriau..Cem. Date of Burial May 2L1.,1959 19
(If body la to be temporarily held,fill in space later)
Thu Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to.J.am.eA...S...P.Qttf;r ..1..?:Lorii~an..Aue. ..Gla .$...Ral�.•s
(Name) Address)
the Undertaker to hold temp ril and Inte the body.
(Undertaker or_person having charge of corpse) (Inte rem ve es.o&he dispose of(state howl)
Date y...2 ,....59 19 (Signed 2-.,_ u / -...R-Q..
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crematr n) of a body to any part of the State (w,bject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date ' `./
(Interment or
(:'7
{ to ry, Crematorium, e tc.}
7
Section / Lot No. Grave No.
(Signed) 7-2 e ��
L.,
(Yeraon in 04cti
Addresr' �/ f r fL✓zi�
Person in charge must return this Permit tot
the Registrar of his District within SEVEN (7) DAYS
fran above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the words
"No person in charge," mad FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.